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Duke Connected Care, a community-based, physician-led network, includes a group of doctors, hospitals and other healthcare providers who work together to deliver high-quality care to Medicare Fee-for-Service patients in Durham and itssurrounding areas.

DukeWELL Team Lead Functional Job Description

The Team Lead oversees a team of 6-12 team members working in-office, hybrid, or fully remote within the PHMO. As a member of the PHMO leadership team, the Team Lead collaborates with other PHMO leadership team members to ensure team goals and responsibilities are effectively achieved. In partnership with PHMO managers, directors, and senior leadership, the Team Lead identifies, plans, and implements activities that drive best-in-class performance aligned the PHMO roadmap, while ensuring compliance with PHMO and DUHS policies and procedures. Additionally, this role may engage with DUHS entity leadership, including direct care teams across multiple sites, to engage, foster, and maintain strong PHMO relationships through consistent and effective communication and collaboration.

The Team Lead is essential in driving operational excellence, fostering team development and change management, and ensuring high-quality care and service delivery within PHMO.

General Description of the Job Class

The Team Lead assumes additional responsibilities beyond their primary job classification, providing operational oversight and functional expertise in their designated area within PHMO. This role ensures team efficiency, compliance with program and contractual requirements, and alignment with PHMO goals. Areas of focus may include specific populations, quality assurance and improvement, engagement and referral processes, clinical conditions, education and training, and filling in for frontline team members as needed.

In addition, the Team Lead is responsible for program development, continuous process improvement, and effective communication with PHMO leadership and other relevant entity leaders. As a key member of an interdisciplinary team, the Team Lead plays a critical role in enhancing whole-person care, quality outcomes, and care transitions.

Duties and Responsibilities of this Level

• Project Coordination & Outcome Tracking: Monitors and coordinates team-specific projects, collaborates with PHMO colleagues, and tracks outcomes with support from the data team.
• Intervention Implementation: Ensures timely implementation of appropriate interventions for identified populations following established policies and procedures, and recommends improvements when gaps are identified.
• Performance Enhancing and Benchmarking: Supports team members in identifying systemic opportunities, strengths, and performance benchmarks to improve payer relations, care management, care transitions, and gap closure. Uses data from multiple sources for targeted outreach, education, and intervention strategies.
• Employee Engagement & Oversight: Conducts monthly individual team member and team meetings to provide updates, training, coaching, and recognition. Engages with individual team members at least monthly to review and discuss performance related to the relevant EJR and team outcomes.
• Observation & Training: Shadows each direct report at least once per evaluation period, or more frequently if concerns arise. Conducts individual and group training to address workflow, documentation, and patient care needs. Is an integral and active participant in onboarding and training new team members.
• Time & Attendance Management: Manages team member time and attendance within the API system.
• Quality Assurance & Auditing: Performs routine team member audits within relevant systems (e.g., data management system, electronic health record (EHR), and recorded calls) to assess quality, clinical care, education accuracy and appropriateness, process adherence, and customer experience. Provides timely feedback and oversight.
• Organizational Engagement: Attends and actively participates in identified PHMO/DukeWELL meetings, training sessions, and initiatives.
• Relationship Management: Develops and maintains strong relationships with internal and external stakeholders and customers across Duke Health. ?

General Description of the Job Class

The Population Health Care Manager is responsible for delivering clinical expertise to manage health care needs of specific patient populations across the continuum of care with a goal of improving patient health outcomes and reducing unnecessary utilization and cost. This role functions as an integral part of an interdisciplinary team and a patient's care team to optimize clinical outcomes through a seamless model of transitions, access, and care. This role focuses on improving the health status and connection to resources, preventive care, hospital follow-up, and ongoing healthcare for individuals with chronic health conditions as well as addressing frequent hospital and emergency department utilization, and medical, behavioral health, and psychosocial needs by performing care management and care coordination functions in a variety of settings that include a patient's home, community, and clinic.

These functions include:

• Disease management and chronic disease support
• Timely completion of clinical assessment and patient-centered care plan development, facilitation, and implementation
• Transitional Care Management / care transition support inclusive of functions of placement into the right setting of care (e.g., skilled nursing, assisted living, home with caregiver support)
• Assessment of and connection to resources and treatment for health, social, and behavioral needs
• Patient activation and coordination for quality and preventive care gap closure
• Assistance with and completion of medication reconciliation, access, education, and adherence

Duties and Responsibilities of this Level

• Manages a designated caseload to complete timely development, completion, and implementation of assessments, care plans, and appropriate interventions for identified patient population to determine patient health, social situation, physical environment, behavioral health, substance use, expressed trauma, economic status, and education to patients while exercising discretion and independent judgment.
• Provides individualized treatment plans to address barriers and identified concerns by accessing systematically identified data from multiple sources such as patient medical records, claims, and

program metric reports to target recipient(s) and provider(s) for outreach, education, and intervention. Performs targeted interventions to assist patients with connection to primary care providers and other health care resources.

• Involves the patient and their support systems (i.e. caregiver, family, etc.) in the decision-making process. Uses a patient-centric, collaborative partnership approach to assist the patient with improved self-management and identifying barriers through a "whole-person" approach, inclusive of medical, psychosocial, behavioral, and spiritual needs.
• Utilizes proven processes to measure a patient's understanding and acceptance of the proposed plan(s), his/her willingness to change, and his/her support to maintain health behavior change.
• Applies teaching and learning theories to assist patients and families with physical and emotional impact of body changes and chronic illness.
• Monitors quality and effectiveness of interventions to the population by setting long term and/or short-term specific, measurable goal(s).
• Maintains timely documentation of all care management activity in Maestro, and other documentation systems relevant to the position.
• Effectively communicates and coordinates with appropriate care team members to minimize fragmented care and foster appropriate utilization of services. This includes navigating transitions of care generally from hospital or facility to home or community facilities.
• Facilitates interdisciplinary communication among care team members to include specialists, PCP, RN, psychiatrist and other key providers. Interfaces with key providers across the care continuum (e.g. discharge planners, social workers, physicians, psychiatrist, etc.) within the hospital, primary care practices, public health and social service departments, as well as behavioral health agencies and other community resources to assure that patients are linked to and engaged in services.
• Provides on-site, community, and telephonic outreach to patients, providers, and community stakeholders assisting with identification of treatment history, diagnoses and patient care components both internally and externally to ensure that services provided are sensitive to the needs of individual patients and consider ethnic and cultural backgrounds.
• Connects with patients and other care team members in a variety of settings, to include patient homes, community agencies and other locations, primary care practices, and telephone and other virtual platforms. This position may require home visits based on business rules and clinical need of identified patient population.
• Participates in quality assurance/performance improvement activities as requested.
• Provides feedback to Team Lead, management, and executive leadership that will enhance negotiations with payers, improve care management, and/or address gaps in care.
• Develop and maintain positive relationships with customers internal and external to Duke Health System.
• Provide other related duties incidental to the work described herein.

Required Qualifications at this Level

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Education

Bachelor's degree in a clinical field such as Nursing, Counseling, Social Work, Therapy, Allied Health, or community health related fields. BSN highly preferred

Experience

3 years of relevant clinical experience required.

Degrees, Licensures, Certifications

Candidates with a BSN must have current or compact RN licensure in state of NC Candidates with a Master's degree (e.g., psychology, social work, counseling, or related behavioral health program) must have a current licensure by one of the following NC Boards: Licensed Clinical SocialWorker (LCSW), Licensed Clinical Addiction Specialist (LCAS), or Licensed Clinical Mental Health Counselor (LCMHC) AND All candidate/employees require a case management certification (ACM,CCM, or ANCC) within 3 years of hire.

POPULATION HEALTH CARE MANAGER
Job Level: G2

Duke is an Affirmative Action/Equal Opportunity Employer committed to providing employment opportunity without regard to an individual's age, color, disability, gender, gender expression, gender identity, genetic information, national origin, race, religion, sex, sexual orientation, or veteran status.

Duke aspires to create a community built on collaboration, innovation, creativity, and belonging. Our collective success depends on the robust exchange of ideas-an exchange that is best when the rich diversity of our perspectives, backgrounds, and experiences flourishes. To achieve this exchange, it is essential that all members of the communityfeel secure and welcome, that the contributions of all individuals are respected, and that all voices are heard. All members of our community have a responsibility to uphold these values.

Essential Physical Job Functions: Certain jobs at Duke University and Duke University Health System may include essential job functions that require specific physical and/or mental abilities. Additional information and provision for requests for reasonable accommodation will be provided by each hiring department.

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About Duke University Health System

As a world-class academic and health care system, Duke Health strives to transform medicine and health locally and globally through innovative scientific research, rapid translation of breakthrough discoveries, educating future clinical and scientific leaders, advocating and practicing evidence-based medicine to improve community health, and leading efforts to eliminate health inequalities.

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